Craniovertebral junction tuberculosis: a case report and review of the literature

Stabilizing the unstable: Tuberculosis of the odontoid process with atlanto-occipital instability-Case report and review of literature

Key Clinical Message

Tuberculosis (TB) of the odontoid process is a rare but potentially, a debilitating condition. Surgical intervention, in the form of stabilizing the spine and decompressing the spinal cord, offers a tailored approach to managing this condition effectively and improving prognosis.

Abstract

Odontoid process tuberculosis (TB) is a rare condition that can cause spinal instability and neurological complications. Diagnosis of odontoid process TB is difficult and requires a combination of clinical, radiographic, and histopathological examinations. This report describes the treatment of a 46-year-old female with quadriparesis and intermittent fever. Radiological findings showed TB of the odontoid process with atlanto-axial dislocation causing compressive myelopathy. She underwent C1-C3 decompressive laminectomy and stabilization from C1 to C5. GeneXpert for TB was positive and she was started on anti-tuberculous medications. She regained power gradually and at 1 year follow-up she was ambulant without any support. The C1-C5 lateral mass screw and C1-C3 decompressive laminectomy approach, as highlighted in this case, offers an effective solution, enhancing patient quality of life, and preventing disease progression.

Cervical spine TB - Current concepts in management

OBJECTIVE

Cervical tubercular disease (CTB) is a rare pathology and constitutes 3-5% of all spinal TB. It includes atlantoaxial TB and sub-axial TB. As the literature evidence on this subject is scarce, majority of issues concerning CTB are still controversial. The current narrative review comprehensively discusses the various aspects related to CTB. Literature search: An elaborate search was made using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis, on pubmed and google (scholar.google.com) databases on 2 December 2020. We identified crucial questions regarding CTB and included relevant articles pertaining to them.

RESULTS

The initial search using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis yielded 4128, 76, 3 and 9 articles on 'pubmed' database, respectively. A similar search using the aforementioned keywords yielded 1,96,000, 2130, 117 and 728 articles on 'google scholar' database. The initial screening resulted in the identification of 178 articles. Full manuscripts were obtained for these articles and thoroughly scrutinised at the second stage. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 41 articles were included.

CONCLUSION

AATB and SACTB constitute 0.3 to 1% and 3% of spinal TB, respectively. The incidence of neuro-deficit in CTB is significantly more than other spinal TB. The general principles of management of CTB are similar to spinal TB elsewhere and medical therapy remains the cornerstone. Surgery is advocated in specific scenarios involving gross neuro-deficit, later stages of disease with significant bony/ligamentous disruptions, altered sagittal balance, drug resistance, and poor response to medications. The surgical approaches for AATB include anterior-alone, posterior-alone and combined approaches, although posterior access is the most preferred. Most of the studies on SACTB have supported the role of anterior approach. Additionally, posterior stabilisation may be necessary in specific scenarios. The overall long-term outcome in CTB is favourable.

Rhombencephalitis in cocaine-induced nasal septal perforation and skull base erosion

Rhombencephalitis is a rare and potentially fatal condition involving the brainstem, with infectious, autoimmune, and paraneoplastic etiologies. We present a patient presenting with left-extremity weakness and dysphonia who had brainstem imaging findings suggestive of rhombencephalitis. We suspect that the case was due to inoculation of the brainstem from nasopharyngeal adenoviral infection. Due to heavy cocaine use, extensive basiocciput erosion led to direct contact between the brainstem and the nasopharyngeal mucosa. The patient's milder clinical course might have been due to some degree of pre-existing immunity against adenovirus. Additionally, clinicians need to be aware of the proximity of the brainstem to the nasopharynx when there is basiocciput erosion, due to the potential risk of injury during instrumentation.

Sagittal Atlantoaxial Joint Inclination and Reduction Index Values for Diagnosis and Treatment of Irreducible Atlantoaxial Dislocation

BACKGROUND

Irreducible atlantoaxial dislocation (IAAD) is a disorder of atlantoaxial joint instability with various causes. The diagnostic criteria for IAAD are variable. The diagnosis of IAAD is mainly based on preoperative and intraoperative traction results, as well as the physician's experience, with no relatively uniform guidelines for the selection of treatment. This study evaluates sagittal atlantoaxial joint inclination (SAAJI) and reduction index (RI) values for diagnosis and treatment of IAAD.

MATERIALS AND METHODS

24 IAAD patients treated in our hospital from January 2008 to July 2014 were retrospectively analysed. Patients included were 13 males and 11 females, with a mean age of 43 years. The various causes for IAAD were atlantoaxial transverse ligament rupture (n=3), old dens fracture (n=15), occipitalization of the atlas (n=6). The patients were divided into two groups. group A underwent anterior release with posterior reduction and fixation; Group B underwent posterior reduction and fixation; 12 healthy individuals served as controls. SAAJI and atlas-dens interval (ADI) values before and after traction were measured, and RI was calculated. Imaging data were analyzed.

RESULTS

The mean SAAJI values were as follows: left, 5.6 ± 1.9° and right, 5.1 ± 2.1° in the control group; right, 39.5 ± 6.0° and left, 38.8 ± 5.8° in Group A; and right, 23.1 ± 7.0° and left, 23.9 ± 6.1° in Group B. There was no significant difference in the SAAJI values of the three groups (P < 0.05). The mean RIs in Groups A and B were 17.6 ± 9.3% and 34.4 ± 5.2%, respectively, and the difference was statistically significant (P < 0.05). There were obvious negative correlations between the SAAJI and RI values in Groups A and B.

CONCLUSIONS

SAAJI and RI can be used as important imaging indicators to determine the reversibility of IAAD. If the RI value is >27.9% and SAAJI value is <32.5°, reduction and fixation can be achieved by the posterior approach alone; otherwise, a combination of anterior and posterior approaches would be necessary.

Tuberculous Spondylitis of the Craniovertebral Junction

Craniovertebral junction tuberculosis is rare, accounting for 0.3 to 1% of all tuberculous spondylitis cases. MR imaging is the modality of choice to detect bone involvement, abscess formation and subligamentous spreading of the pus, to differentiate from other lesions affecting the craniovertebral junction, and to determine the efficacy of treatment. Given the fact that surgical treatment of patients with craniovertebral junction tuberculosis has been associated with a high mortality rate ranging up to 10% and recurrence rate ranging up to 20%, conservative is the standard of treatment for most patients. This article presents a patient with craniovertebral junction Mycobacterium tuberculosis infection diagnosed with CT-guided biopsy. A halo vest was applied and antituberculous treatment with rifampicin, isoniazid and ethambutol was initiated. At 6-month follow-up, the patient was asymptomatic; CT of the cervical spine showed healing of the bony lesions. The halo vest was removed and physical therapy was recommended. Antituberculous treatment was continued for a total of 18 months, without any evidence of infection recurrence.